Introduction
Opioid Substitution Therapy has been a controversial topic. Somehow
it is easier for the addiction recovery industry to accept medications such as Disulfiram
with its aversive effect or acamprosate which does not carry the risk of
approximating the state of alcohol intoxication and because studies have suggested
that it is only effective in conjunction with psycho-social interventions. OST,
on the other hand, uses opioid agonists or partial agonists that act in similar
ways to the drugs of dependence, albeit without the same quality of high, and
this, some have suggested, shifts the addiction from opioid dependence to
another dependence and may be of more harm than good to the addict.
Methedone, the original medication of choice in OST, has
been described as both saviour and devil by addiction professionals, lay
counsellors and those recovering from or still suffering from addiction. More
recently Buprenorphine has taken centre stage. At any rate, it has always been
proposed that it is “Medication Assisted Treatment”, with treatment being some
form of psycho-social intervention, while it is the medication that is the
add-on in this process of recovery.
Because of this thinking OST has largely been used as a temporary
means of managing the short-term issues of dependence i.e. detox. Recent
research, however, has shown that rather than being a supplement to treatment,
OST may be the treatment itself. Two recent studies both suggest that adjunctive
counselling and/or CBT do nothing to improve outcomes. These are also consistent
with previous studies, although more adamant (Fielin, Pantalon, & et al, 2006).
This research flies in the face of traditional “recovery”
based thinking and there is now a debate between two seemingly opposing factions.
It is “Recovery” versus “Treatment”, and as more and more addiction treatment
professionals accept that addiction is a brain disease that can be treated by
medication, and as medication for other addictive substances emerges, this
topic is going to be more hotly contested. And there is a lot at stake: If
addiction can be treated by a series of 15 minute General Practitioner office
based interventions a lot of people will be out of a job, the rehab industry
would shut down and there would be little need of 12-step fellowships. On the
other hand the insurance companies would save millions while the pharmaceutical
companies would make billions.
So what is this debate all about? Let’s start by looking at
the two research papers I have mentioned above.
The Research
One study (Weiss, Potter, & et al, 2011) looked at over 600
prescription opioid dependent individuals who received buprenorphine in a
2-phase randomized control trial.
What the study concluded was:
·
Addiction counselling made little or no
difference to outcomes
·
Tapering, even after 12 weeks resulted in poor
outcomes
·
Those who were stabilized on buprenorphine had
considerably better outcomes
·
Physician initiated office based treatment is possible
For the purposes of this article,
what is important in these findings is that drug counselling made almost no
difference. What should be noted, however, and what may be of importance, is
that the majority of the patients in this study where employed, well educated,
had short histories of opioid dependence and virtually no polysubstance use.
Although this study does not provide
a complete description of the Opioid Dependence counselling they used, it
sounds a lot like psycho-education and CBT: “Counsellors educated patients
about addiction and recovery, recommended self-help groups, and emphasized
lifestyle change. Using a skills-based format with interactive exercises and
take-home assignments, ODC over a wider range of relapse prevention issues in
greater depth than did Standard Medical Management, including coping with
high-risk situations, managing emotions, and dealing with relationships.”
In early 2013 headlines proclaimed
“CBT is not effective in treating heroin addiction” (or words to that effect) after
the publication of a study by David Fielin and others at Yale University School
of Medicine (Fiellin, Barry, & al, 2013).
This study “conducted a 24-week randomized
clinical trial in 141 opioid-dependent patients in a primary care clinic.” One
group received only physician management while getting their buprenorphine,
while the other group received this plus CBT.
The conclusion: CBT added no
benefit.
Why these findings are
controversial is because it has always been assumed that psycho-social
interventions form the core of addiction treatment and recovery from the
addicted state. A Cochrane Review entitled “Psychosocial and pharmacological
treatments versus pharmacological treatments for opioid detoxification” (Mato, Minozzi, Davoli, & Vecchi, 2011) concluded: “The
review authors searched the medical literature and found evidence that
providing a psychosocial treatment in addition to pharmacological detoxification
treatment to adults who are dependent on heroin use is effective in facilitating
opioid detoxification.” This seems to conflict with the findings of these other
studies.
What research certainly does tell us more clearly is that
Opioid Maintenance Therapy does keep patients engaged in therapy and keeps them
abstinent longer (Mattick, Breen, Kimber, & Davoli, 2009) (Sees, et al., 2000) (Kleber, 2007) (Caldiero,
Parran, CL, Piche, & B, 2006) (Donovan, Knox, Skytta, Bayney, & DiCenzo, 2012). There appears to be
little research doubt that open-ended Maintenance Therapy is better than using
OST as a means of detox.
So why the controversy?
If one looks at the various discussions that take place
between addiction professionals and those recovering from addiction on sites
such as The Fix and LinkedIn, we can easily see that two camps have emerged.
I know that many will criticise the names I have given these
two camps, they are not perfect, and I know that there are many who fit
somewhere between the two, but for the purposes of this article I have chosen
these names and I have defined them as such:
Those that believe that abstinence means that long-term OST
is not an option, or is somehow second rate, and that there should always be
the goal of medication-free recovery. They also believe that medication is an
adjunct to other treatment modalities.
This camp says that indefinite OST is what the research is
saying is effective, and they further believe that OST is the treatment in
itself, and anything else is at best an adjunct, and often not necessary.
Until recently you could not go to Hazeldon and be on OST.
Most of the Minnesota model based recovery industry is still firmly in the “recovery”
camp. They are/were firmly abstinence based. In the world of celebrity and television the
program “Celebrity Rehab with Dr Drew” has reinforced this school of thought:
Dr Drew claims that methadone “takes your soul away”. To reinforce this view,
here is an extract from an article from the Canadian press:
Harm reduction just keeps addicts enslaved
By Jon Ferry, The Province March 13, 2013
The UN
Commission on Narcotic Drugs is meeting in Vienna this week to recommend
measures to combat the world drug problem.
But in
Vancouver, the war against illegal drugs appears to have been won already by
those who favour "harm reduction," with its publicly funded crackpipe
kits, safe-injection rooms and "free" heroin and methadone fixes.
This does
little more than apply a Band-Aid — as opposed to abstinence-based treatment,
which actually gets people off drugs but is frowned upon by the politically correct
powers-that-be.
Here is another typically representative comment from a
LinkedIn discussion in a closed Addiction Professionals group:
I guess I just find it a little disappointing
that after 50 years of research and study, the best we've come up with for
opioid addicts is a way to make them more successfully dependent on an opioid.
There are whole websites dedicated to the cause, and they
are evangelical about the matter: check out the site called www.subsux.com.
Filled with graphic descriptions and an alternative dictionary of expletives,
the editor of the site says that:
If you want to read actual unedited
experiences that aren't sponsored by the pharmaceutical companies or filled
with suboxone promoting sub sucking zombies telling the "victim" that
the reason their wd's are lasting so long is that they tapered wrong, or that
it wasnt the sub but all the drugs they did prior to sub, or depression then
you're in the right place.
On the other side of this camp are the likes of Dr Mark
Willenbring, former director of Treatment and Recovery Research at the National
Institutes of Alcohol Abuse and Alcoholism and now CEO of Altyr, who made the
following comments in a discussion on the LinkedIn Addictions Professionals
Group:
As for whether opioid medication is a black or white issue,
it is. This is not one of those situations where some studies are positive,
some negative, and only in the meta-analysis can you conclude whether something
works. This is a situation where every quality study ever done comparing
abstinence to maintenance shows a very powerful effect for medication. It is
the primary treatment recommendation of the World Health Organization. Opioid
agonist therapy is more effective than treatments for high cholesterol,
diabetes, heart disease or arthritis.
What happened to requiring counseling along with Suboxone?
We found out it didn't matter for most people, unless they had co-existing
mental disorders. As I posted in my blog, it's not medication-assisted
treatment, the medication is the treatment. And like it or don't but the
relapse rate is >90% when people go off of it, or methadone, even after
being on one of them for months (or years) and being given counseling of a
quality far superior to anything available in the community. These are
established facts, no matter how distasteful one might find them. Nasty little
thing about scientific research is that it doesn't always reinforce what we
already "know" to be The Truth. But that's what the scientific method
is for.
And as professionals we are ethically bound to tell our patients what the evidence shows even if (or especially if) we wish the facts were different. As Bernard Russell once said: "When the facts change, I change my mind. What do you do, sir?"
And then from private correspondence with Dr Willenbring:
My own experience is that for many people
with opioid addiction, agonist therapy is all they need. Others who have
additional psychopathology need other services as well. It does need to be
individualized. What I like about this finding, along with others, it that it
disputes the prevailing notion that therapy or counseling is a required element
of recovery, when it clearly is not. I think we cling to that belief mostly out
of (unconscious) self interest.
And then again from the otherside:
I've sent plenty of addicts to OST/OMT programs but I don't
like the idea of referring to a program with little or no treatment and no exit
plan to speak of. This came to my attention recently through a friend who's
trying to help his sponsee leave bupe maintenance after 3 years of otherwise
productive recovery. It seems to be a pretty difficult process, which makes me
think bupe isn't as easy to detox from as I had been told.
The other thing that concerns me: pretty soon we're going to have a million addicts on bupe OMT.
And in case you were wondering about my own beliefs, here is
my response:
By no manner of speaking is long-term OST addiction, or
keeping a person addicted. To equate dependence and addiction is also
misguided. There are many amongst us who need long-term or even life-long OST
and to deny them that is unethical. Research tells us that OST is the primary
treatment in many cases. But as they say, one good personal anecdote destroys
10 years of double blind studies. No matter what our personal feelings, if we
are addictions professionals, OST and harm reduction HAVE to be on the front
page of the menu of treatment options, otherwise we are nothing more than
quacks.
But does that mean that I am firmly in the treatment camp?
Certainly not. I have a lot of worries about us seeing OST as a complete
treatment by itself. I have criticised the Yale study in a previous article
which can be found on my blog site: www.addictioncapetown.blogspot.com.
Some of my thinking about long-term use has changed in the face of research,
but essentially my criticisms of the research findings as reported and
perceived still stand:
Most of my criticism of the Yale study can be extended to
the Weiss study, and indeed most other studies that propose medication as the
end in itself revolve around the following main issues:
·
They measure the wrong thing
·
They measure it over too short a time
·
They exclude some significant populations
·
They focus on CBT as the counselling approach
with which to compare outcomes
·
They ignore other aspects of recovery
They measure the wrong thing
What should we measure when it comes to recovery from
addiction? If we regard abstinence as the measure of success, then certainly
OST is successful. If we see heroin addiction as equalling heroin dependence, I
think we are missing the root of addiction. Through various processes, and on
many levels, those with an addictive disorder have developed a set of thinking
patterns and behaviours which are often not compatible with the achievement of
their life goals. The drug has a salience that exceeds mere physical dependence,
there is a lot invested in the processes and relationships of the addicted
state and to simply measure abstinence is not giving a clear picture. The Weiss
research reports that there is little or no change in levels of criminal behaviour,
for instance (Weiss, Potter, & et al, 2011).
We should be measuring quality of life as well, in my
opinion.
Most studies, with a few notable exceptions, report on
relatively short-term outcomes. Certainly the studies I have referred to in
this article have focused on a maximum of 6 months after treatment initiation.
We also know that in these studies if the patient discontinued use the relapse
rate was >90%. My question is: Is long-term OST sustainable? We know that
adherence to chronic medication is not good – about 50% (Brown & Bussell, 2011), so this does not
bode well for continued sobriety.
The perception created by the Yale paper, especially evident
in the interviews with the researchers and in the press, is that those
suffering with opioid addiction can be cured with medication. What they fail to
point out is that within the “addicted” group there are a large number of
patients with comorbidity and those who clearly self-medicate. There is little
doubt that these populations require further interventions, and if we start
presuming that a simple office initiated medication based regimen will be
sufficient for this population we are naive.
They focus on CBT as the counselling approach with which to compare outcomes
I
agree that CBT is a fair place to start when comparing various modalities of
treatment for addictive disorders. CBT seems to be the recommended
intervention, but then again I have similar criticisms of CBT studies as I do
of the Yale study. Most studies focus on abstinence not quality of life and
short periods of up to 12 months after treatment initiation. Most people
seeking treatment have been users of their drugs or activities of choice for
many years. The mean using years in the Yale study was 8.
CBT
in addictions treatment focuses on the “here and now” and is essentially
designed to bring about behaviour modification, prevent relapse and provide techniques
to reduce cravings. It does this fairly well compared with other modalities in
short-term comparisons, but there is little difference when compared with other
modalities in longer term studies.
So,
essentially, you are double-treating the same issue. No wonder CBT seems to add
little value. Medications work better when it comes to short-term behaviour
modification. But do they work better in the long-term? We will have to wait
and see.
My criticisms of the Recovery Camp are:
·
They place undue emphasis on 12-Step recovery
·
They believe OST is not abstinence
·
They tend to ignore the evidence
Both in the outpatient and inpatient settings, the recovery
camp tend to place too much emphasis on 12-step programs. In-patient facilities
often charge a fortune for what are essentially nothing more than a bunch of
12-step meetings in a draconian environment. Out-patient settings are much the
same and often focus on confrontational styles of intervention as laid out in
many 12-step facilitation manuals. In my mind, while 12-step programs are a
fantastic and free resource and undoubtedly work for some, they have little
place as a stand-alone treatment modality in the professional setting.
Along with 12-step recovery comes a number of other issues
that are problematic in the professional addiction care setting, which I will
not discuss here, but there is one major problem:
Abstinence is where it starts and ends in the recovery camp.
You must abstain from all mind-altering drugs. Full stop. Some 12-step programs
will not allow those on OST to hold service positions. The more radical ones
say that taking an opioid for pain management is relapse. Just like the
treatment camp, but in reverse, they see dependence as addiction.
To consider one of these camps as either definitive or irrelevant
would be missing an opportunity to find a more complete and balanced approach
to addiction care. And although I used him as an example of the “treatment”
camp, Dr Willenbring also wrote this to me in our private correspondence:
And, BTW, I use both CBT and brief
psychodynamic therapy myself, as well as supportive therapy.
Here in the USA, which is so dominated by
12-step ideology, it needs to be said again and again that not everyone has to
go to AA the rest of their lives, and that 12-step counseling is not always
needed. That may color my remarks. What I was trying to do in the blog was to
counter the notion that 12-step rehab is the necessary and sufficient condition
for recovery. In other countries where the 12-step influence isn't so strong,
that might come across as too pharmacotherapy oriented, which I am not. I do
more psychotherapy that most of my psychiatry colleagues here, where the norm
is strictly psychopharmacology.
Perhaps the answer lies in knowing when and how to apply
each of these modalities. I would agree with Avial Goodman (Goodman, 2001) who suggests that there are 4 phases of
recovery from an addictive disorder:
1.
Behaviour modification
2.
Stabilisation
3.
Character Healing (personally I prefer Capacity Building)
4.
Self-Renewal
I would suggest that medication and short term “treatment” therapies
like CBT (as applied in addiction treatment), are best suited to the first two
phases while more “recovery” orientated interventions, such as life-skills,
psychodynamic therapies, longer term CBT and peer support groups are more
suitable for the final two phases.
So where does long-term OST fit in? Well, for some opioid
addiction is a means of self-medicating a sluggish opioid system, and so they
would need to compensate for this in order to feel “normal”. Perhaps this is pre-existing
or as a result of extended substance abuse, either way the opioid absent system
is not a comfortable one, and so they would find themselves vacillating between
behaviour modification and short-term stabilisation. Surely for this individual
it would be better for them to stay on indefinite OST so as to maximize their
ability to engage in long term therapy?
Further, I would like to suggest that addiction takes place
across three planes:
·
Neurobiology – Neurochemistry
·
Thought – Behaviour (short-term and long-term)
·
Microsystem – Macrosystem
Each of these planes interact with and influence each other.
So, for example, the neurobiology – Neurochemistry plane will have an effect on
the other planes, to a greater or lesser degree. In the case of OST, this will
have an almost immediate effect on the short-term Thought-Behaviour plane (the
same plane where brief CBT therapies operate). These changes in behaviour can,
in turn, influence the Systems plane. Positive feedback from the system will in
turn influence the Thought-Behaviour plane and the Neurological plane and so
on. In cases where there has not been long term abuse that has caused
significant damage to the Thought-Behaviour plane or the Systems plane, I would
suggest that OST may be enough to bring to life the process described here, and
this will be enough for the capacity building and self-renewal mentioned above
to take place.
For most opioid abusers, however, the Systems and long-term
Thought-Behaviour planes have been so influenced by the Neurological Plane
through the constant Neurochemical and behavioural influences of the opioids,
that simple medication is not enough. I have spoken to many former substance
users whose longing is not for the drug, but for the lifestyle. It is about the
excitement and chaos and sense of control over one’s feelings and being able to
self-regulate on a whim. It is the using friends, the sense of rebellion and
the easy means of coping that have all become expected and easily attained by
drug use that hold a far stronger allure than mere physical dependence. These
aspects will seldom be addressed by OST.
And so, in conclusion, I would say: Treatment treats
dependence, and helps one disrupt the addictive cycle, recovery treats
addiction and helps build the capacity to engage in life without illicit
substance use, and in many cases both are needed to in varying degrees to reach
the goal of a meaningful existence.This
all brings as back to the first principle of addiction treatment: “There is no
one-size fits all solution.”
Works Cited
Brown, M., & Bussell, J. (2011). Medication
Adherence: WHO Cares? Mayo Clinical Proceedings, 304-314.
Caldiero, R., Parran, T. J., CL, A., Piche, & B.
(2006). Inpatient initiation of buprenorphine maintenance vs. detoxification:
can retention of opioid-dependent patients in outpatient counseling be
improved? American Journal of Addiction, 15(1):1-7.
Donovan, D., Knox, P., Skytta, J., Bayney, B., &
DiCenzo, J. (2012). Buprenorphine from detox and beyond: preliminary
evaluation of a pilot program to increase heroin dependent individuals'
engagement in a full continuum of care. Journal of Substance Abuse
Treatment, 44(4):426-432.
Fielin, M., Pantalon, M., & et al. (2006).
Counseling plus Buprenorphine–Naloxone Maintenance Therapy for Opioid
Dependence. The New England Journal of Medicine, 355:365-374.
Fiellin, D., Barry, D., & al, e. (2013). A
Randomized Trial of Cognitive Behavioral Therapy in Primary Care-based Buprenorphine.
The American Journal of Medicine, 126(1):74e11-74e17.
Goodman, A. (2001). What's in a Name? Terminology for
Designating a Syndrome of Driven Sexual Behaviour. Sexual Addiction and
Compulsivity, 8: 191-213.
Kleber, H. (2007). Pharmacologic treatments for
opioid dependence: detoxification and maintenance options. Dialogues
Clinical Neuroscience, 9(4): 455-470.
Mato, L., Minozzi, S., Davoli, M., & Vecchi, S.
(2011). Psychosocial and pharmacological treatments versus pharmacological
treatments for opioid detoxification. The Cochrane Collaboration, Wiley.
Mattick, R., Breen, C., Kimber, J., & Davoli, M.
(2009). Methadone maintenance therapy versus no opioid replacement therapy
for opioid dependence. The Cochrane Review.
Sees, K., Delucchi, K., Masson, C., Rosen, A., Clark,
H., Robillard, H., et al. (2000). Methadone maintenance vs 180-day
psychosocially enriched detoxification for treatment of opioid dependence: a
randomized controlled trial. Journal of the American Medical Association,
283(10)1303-10.
Weiss, R., Potter, J., & et al. (2011).
Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone
Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled
Trial. Arch Gen Psychiatry, 68: 2011-2121.